Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

Experiences of moral distress in a COVID-19 intensive care unit: A qualitative study of nurses and respiratory therapists in the United States

The COVID-19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID-19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to consider needs for additional support. Twenty semi-structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges.

A systematic scoping review moral distress amongst medical students

BACKGROUND

Characterised by feelings of helplessness in the face of clinical, organization and societal demands, medical students are especially prone to moral distress (MD). Despite risks of disillusionment and burnout, efforts to support them have been limited by a dearth of data and understanding of MD in medical students. Yet, new data on how healthcare professionals confront difficult care situations suggest that MD could be better understood through the lens of the Ring Theory of Personhood (RToP). A systematic scoping review (SSR) guided by the RToP is proposed to evaluate the present understanding of MD amongst medical students.

METHODS

The Systematic Evidence-Based Approach (SEBA) is adopted to map prevailing accounts of MD in medical students. To enhance the transparency and reproducibility, the SEBA methodology employs a structured search approach, concurrent and independent thematic analysis and directed content analysis (Split Approach), the Jigsaw Perspective that combines complementary themes and categories, and the Funnelling Process that compares the results of the Jigsaw Perspective with tabulated summaries to ensure the accountability of these findings. The domains created guide the discussion.

RESULTS

Two thousand six hundred seventy-one abstracts were identified from eight databases, 316 articles were reviewed, and 20 articles were included. The four domains identified include definitions, sources, recognition and, interventions for MD.

CONCLUSIONS

MD in medical students may be explained as conflicts between the values, duties, and principles contained within the different aspects of their identity. These conflicts which are characterised as disharmony (within) and dyssynchrony (between) the rings of RToP underline the need for personalised and longitudinal evaluations and support of medical students throughout their training. This longitudinal oversight and support should be supported by the host organization that must also ensure access to trained faculty, a nurturing and safe environment for medical students to facilitate speak-up culture, anonymous reporting, feedback opportunities and supplementing positive role modelling and mentoring within the training program.

The Effect on the Care Behaviors of Nurses Working in Intensive Care Clinics of Moral Distress Experienced During End of Life Patient Care

This research was conducted as a descriptive study in order to examine the effects of the moral problems experienced by nurses working in intensive care clinics on their end of life care behaviors. The data were collected using the Moral Distress Scale and Caring Behaviors Inventory. It was found that 74.5% of the nurses were women and their mean age was 32.60 ± 6.6 years. The frequency of moral distress in the nurses was 44.27 ± 16.25 and total score was 111.02 ± 63.85. There were significant differences in the scores of the concept the use of futile treatment by nurses, the decision not to begin life-support treatment being made only by physicians, and moral distress and discomfort felt by pediatric intensive care nurses (p < .05). A statistically significant relationship was found between total scores of discomfort on moral distress and assurance, knowledge and skills, connectedness, and being respectful on the end of life care behaviors (p < .05).

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers

BACKGROUND

Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic.

OBJECTIVE

To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic.

DESIGN

Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA.

PARTICIPANTS

618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic.

MAIN MEASURES

Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates.

KEY RESULTS

46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs.

CONCLUSIONS

The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Perception of interdisciplinary collaboration between ICU nurses and resident physicians during the COVID-19 pandemic

Multidisciplinary collaboration is the hallmark of quality critical care. Prior studies have shown that nurses and physicians have different perceptions on communication and collaboration in the ICU. The Covid-19 pandemic has served to both strain and strengthen relationships between nurses and resident physicians in the ICU. This study used a survey-based approach sought to identify the similarities and differences between perception of collaboration between ICU nurses and resident physicians taking care of patients during the pandemic, and to identify whether they felt that the pandemic impacted the collaborative spirit of critical care. Although findings from this study suggest that overall residents and nurses perceive collaboration similarly, the COVID-19 pandemic may be differentially affecting the interdisciplinary dynamics of the ICU.

Critical care nurses’ perception of moral distress in intensive care during the COVID-19 pandemic – A pilot study

Objectives

To describe critical care nurses’ perception of moral distress during the second year of the COVID-19 pandemic.

Design/Methods

A cross-sectional study involving a questionnaire was conducted. Participants responded to the Italian version of the Moral Distress Scale-Revised, which consists of 14 items divided in dimensions Futile care (three items), Ethical misconduct (five items), Deceptive communication (three items) and Poor teamwork (three items). For each item, participants were also invited to write about their experiences and participants’ intention to leave a position now was measured by a dichotomous question. The data were analysed with descriptive statistics and qualitative content analysis. The study followed the checklist (CHERRIES) for reporting results of internet surveys.

Setting

Critical care nurses (n = 71) working in Swedish adult intensive care units.

Results

Critical care nurses experienced the intensity of moral distress as the highest when no one decided to withdraw ventilator support to a hopelessly ill person (Futile care), and when they had to assist another physician or nurse who provided incompetent care (Poor teamwork). Thirty-nine percent of critical care nurses were considering leaving their current position because of moral distress.

Conclusions

During the COVID-19 pandemic, critical care nurses, due to their education and experience of intensive care nursing, assume tremendous responsibility for critically ill patients. Throughout, communication within the intensive care team seems to have a bearing on the degree of moral distress. Improvements in communication and teamwork are needed to reduce moral distress among critical care nurses.

CURA: A clinical ethics support instrument for caregivers in palliative care

This article presents an ethics support instrument for healthcare professionals called CURA. It is designed with a focus on and together with nurses and nurse assistants in palliative care. First, we shortly go into the background and the development study of the instrument. Next, we describe the four steps CURA prescribes for ethical reflection: (1) Concentrate, (2) Unrush, (3) Reflect, and (4) Act. In order to demonstrate how CURA can structure a moral reflection among caregivers, we discuss how a case was discussed with CURA at a psychogeriatric ward of an elderly care home. Furthermore, we go into some considerations regarding the use of the instrument in clinical practice. Finally, we focus on the need for further research on the effectiveness and implementation of CURA.

Moral Sensitivity and Emotional Intelligence in Intensive Care Unit Nurses

Moral sensitivity helps individuals resolve moral dilemmas as a precursor to moral decision-making. Intensive care unit (ICU) nurses are at high risk for encountering moral dilemmas and should have the moral sensitivity to recognize moral issues. The activities of ICU nurses in moral decision-making are guided by moral sensitivity but are also based on emotional intelligence (EI). EI, be recognized as an integral part of moral sensitivity with long-standing theoretical foundations. It is necessary to explicate the true role of EI in moral sensitivity through empirical research. To measure the level of moral sensitivity of ICU nurses and determine the relationship between moral sensitivity and EI. We recruited 467 ICU nurses of ten hospitals from March to June 2021 in Hunan Province, China for a cross-sectional questionnaire survey. The moral sensitivity and EI were measured using the Moral Sensitivity Questionnaire-Revised Version into Chinese (MSQ-R-CV) and the Wong and Law Emotional Intelligence Scale-Version into Chinese (WLEIS-C). A self-report questionnaire covered sociodemographic characteristics. The average moral sensitivity score of ICU nurses was 39.41 ± 7.21. The average EI score was significantly positively correlated with the moral sensitivity score (p < 0.001). This study demonstrated that the moral sensitivities of ICU nurses were at medium levels. EI of ICU nurses can indeed affect their moral sensitivity, and the impact of each element of EI should be clarified for practical application.

Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center

BACKGROUND

Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave.

METHODS

We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.

RESULTS

Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001).

CONCLUSIONS

Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Developing a digitally innovative ethics and professionalism curriculum for neonatal-perinatal medicine fellows: a 3-year multicenter pilot study

OBJECTIVES

The purpose of this study was to develop and regionally pilot a digitally innovative curriculum in ethics and professionalism in neonatology and study the effects on trainee knowledge and confidence.

STUDY DESIGN

We developed 13 modules in ethics for neonatology fellows and piloted them at three academic institutions utilizing a flipped-classroom approach. Baseline surveys in ethics knowledge and confidence in approaching ethical dilemmas were compared with repeat surveys after curriculum completion. Pre- and post-tests were also administered for all 13 modules.

RESULTS

Forty-four of 49 eligible fellows participated (90% response rate). Pre/post comparisons demonstrated significant improvements in overall knowledge and in 8/13 modules, as well as improvement in overall confidence and individually when navigating 16/22 ethical dilemmas.

CONCLUSIONS

After completing this curriculum, participants' knowledge scores and reported confidence in approaching ethical challenges significantly improved. Future steps include assessing the effects of this innovative curriculum via an ongoing international pilot.

Association Between Interdisciplinary Collaboration and Leadership Ability in Intensive Care Unit Nurses: A Cross-Sectional Study

BACKGROUND

Interdisciplinary collaboration in the intensive care unit (ICU) is crucial for improving the quality of patient care. Furthermore, interdisciplinary team members need to establish team leadership to function effectively in solving problems. However, the influence of improving leadership ability in nurses on interdisciplinary collaboration efficacy is uncertain.

PURPOSE

This study was designed to clarify the relationship between nursing leadership ability and interdisciplinary collaboration.

METHODS

This cross-sectional study included 3,324 nurses with > 3 years of experience working in an ICU in Japan as participants. The investigation period was from April to September 2016. The developed questionnaire addressed leadership ability (Self-Assessment Inventory of Leadership role for staff nurses) and activities and perceptions related to multidisciplinary collaboration (Collaboration and Satisfaction About Care Decisions). The questionnaires were then collected and mailed.

RESULTS

The 2,063 valid questionnaire responses gave a valid response rate of 61%. Nursing leadership ability was found to be significantly higher in advanced practice nurses (APNs; 78.8 ± 9.5, p < .001) and nurses in higher positions (74.9 ± 8.9, p < .001) than in non-APNs. However, no differences were found in terms of ICU management systems (p = .116). In addition, higher levels of nursing leadership were associated with greater team coordination (β = .212), higher levels of interdisciplinary collaboration in the ICU (β = .196), and the perception of many medical staff members, as well as patients and family members, to be team members (β = .140) and APNs (β = .128; p < .001).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Improving the leadership ability of critical care nurses may impact interdisciplinary collaboration positively. Leadership ability in nurses was shown to be related to a high level of cooperation among multiple healthcare providers. To enhance leadership ability in critical care nurses, nurses must increase their level of knowledge and ability. However, examining and implementing educational methods, including the improvement of coordination ability mainly by APNs, remain a challenge.

How Supportive Ethical Relationships Are Negatively Related to Palliative Care Professionals' Negative Affectivity and Moral Distress: A Portuguese Sample

In the modern healthcare landscape, moral distress has become an increasingly common phenomenon among healthcare professionals. This condition is particularly prevalent among palliative care professionals who are confronted with bioethical issues in their daily practice. Although some studies described the effects of poor ethical climate and negative affectivity on moral distress, how these variables could be incorporated into a single model is still unclear. Thus, this study aims to investigate whether ethical relationships with the hospital could be related to the intensity and frequency of moral distress, both directly and as mediated by professionals' negative affectivity. Sixty-one Portuguese palliative care professionals completed web-based self-report questionnaires. After exploring descriptive statistics, mediation analyses were performed using the partial least squares method. The results indicated that the presence of positive relationships with the hospital reduced the professionals' negative affectivity levels. This, in turn, led palliative care professionals to experience a lower frequency and intensity of moral distress. Being a physician was positively associated with negative affectivity but not with the frequency of moral distress. Considering the protective role of ethical relationships with hospitals, health organizations could consider implementing interventions to improve hospitals' ethical climate and provide staff with ethics training programs.

Moral distress among Iranian neonatal intensive care units' health care providers: a multi-center cross sectional study

Due to the unique nature of the neonatal intensive care unit (NICU) and its moral distress, this study aimed to investigate moral distress in the NICU. This cross-sectional study was conducted on 234 physicians and nurses working in the neonatal wards of eight hospitals. The Corley’s Moral Distress Scale was used to collect data. Findings showed that 25 of the participants were physicians and 209 were nurses. The intensity and frequency of distress among physicians and nurses were assessed as moderate. The mean intensity and frequency of moral distress among nurses and physicians were 48.3%, 41.5% and 46.46%, 15.62% respectively. The results showed that the mean intensity and frequency of distress were higher, however not significantly, among nurses. The intensity and frequency of moral distress had a statistically significant and direct correlation with the intention to leave and the number of staff in each working shift among the nurses. Moral distress in the NICU practitioners was moderate, so addressing this issue and trying to alleviate it was important. Identifying the causes behind moral distress can help adopt appropriate measures to prevent and reduce them.

New approach to assessing and addressing moral distress in intensive care unit personnel: a case study

PURPOSE

To test a new approach to address moral distress in intensive care unit (ICU) personnel.

METHODS

Using principles of participatory action research, we developed an eight-step moral conflict assessment (MCA) that guides participants in describing the behaviour that they have to implement, the effects this has on them, their current coping strategies, their values in conflict, any other concerns related to the situation, what helps and hinders the situation, new coping strategies, and the effect of the preceding steps on participants. This assessment was tested with eight ICU providers in an 11-bed community ICU.

RESULTS

During three one-hour sessions, participants described their moral distress that was caused by the use of ongoing life-support for a patient who the team believed did not prefer this course of care, but whose family was requesting it. Participants experienced frustration and discouragement and coping strategies included speaking to colleagues and exercising. They felt that they were unable to take meaningful action to resolve this conflict. Values that were in conflict in the situation included beneficence and patient autonomy. Based on ranking of helping and hindering factors, the team proposed new strategies including improving consistency of care plans and educating patients' family members and ICU personnel about advance care planning and end-of-life care. After completing this assessment, participants reported less stress and a greater ability to take meaningful action, including some of the proposed new strategies.

CONCLUSIONS

We found this new approach to address moral distress in ICU personnel to be feasible and a useful tool for facilitating plans for reducing moral distress.

Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units

It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician's concept of personhood, or "what makes you, 'you'", we adopt Radha Krishna's Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support.

Managing the end of life in COVID patients. The role of palliative care in emergency departments during the pandemic

Managing COVID-19 patients has been an extremely difficult and dramatic task, especially for emergency departments during the strongest waves of the pandemic in Italy. Medical staff and health professionals were redeployed from their work setting to COVID units; many were overwhelmed by the deaths of so many patients in a very short time. This work aimed to explore palliative care health professionals' and physicians' perceptions of end-of-life care management in COVID units during the first two waves of the pandemic in Italy. Qualitative data was collected through 24 semi-structured in-depth interviews. The participants were palliative care medical and health professionals redeployed, or in a supporting role, COVID units from the most affected areas of northern and central Italy. The interview questions were focused on four thematic areas concerning different aspects of the role and responsibilities of the palliative care specialist (physician and healthcare professional). A brief presentation of the main sociological literature on end-of-life management in hospital contexts will be firstly presented and discussed to offer a theoretical frame. Subsequently, some of the most significant results that emerged from our research will be illustrated concerning the role played by palliative care professionals during the pandemic and the relevance of the palliative care approach in emergency contexts.

Impact of the Coronavirus Disease 2019 Pandemic on Moral Distress Among Nurses and Physicians in Spanish ICUs

OBJECTIVES

To assess the impact of COVID-19 pandemic on moral distress (MD) among healthcare professionals (HCPs) (physicians and nurses) in Spanish ICUs.

DESIGN

Cross-sectional, prospective study.

SETTING

ICUs in Spain.

PARTICIPANTS

HCPs currently working in Spanish ICUs.

INTERVENTIONS

Data were collected via electronic survey with the use of a 50-item questionnaire in two different periods: prepandemic (October-December 2019) and during the second wave of COVID-19 (September-November 2020).

MEASUREMENTS AND MAIN RESULTS

During the prepandemic and pandemic periods, 1,065 (57.1% nurses) and 1,115 (58.5% nurses) HCPs completed the questionnaire, respectively. Higher MD levels were reported during COVID-19 pandemic, particularly among ICU nurses, when compared with the prepandemic period. Before COVID-19, physicians reported significantly higher levels of MD than ICU nurses (80.0 [interquartile range {IQR}, 40.0-135.0] vs 61.0 [IQR, 35.0-133.0]; p = 0.026). These differences disappeared during the pandemic period (81.0 [IQR, 39.0-138.5] vs 74.0 [IQR, 41.0-143.0]; p = 0.837). During the pandemic, younger and less experienced HCPs working in hospital areas that were converted in ICU or in ICUs with multiple occupancy rooms reported higher MD levels. In addition, HCPs who were off work for psychologic burden reported higher MD levels (108.0 [IQR, 66.0-139.0] vs 76.0 [IQR, 40.0-141.0]; p < 0.05). In the prepandemic period, patient-level root causes were the most morally distressing for nurses, whereas physicians reported higher MD on system-level root causes. During the pandemic, both groups reported higher MD on system-level root causes. During COVID-19, significantly more HCPs considered leaving their job due to MD.

CONCLUSIONS

MD has increased among ICU HCPs in Spain during COVID-19 pandemic. Physicians reported higher MD levels than nurses in the prepandemic period, whereas both HCPs groups reported similar MD levels in the pandemic period. Strategies are needed and should be implemented to mitigate MD among HCPs.

Encountering the social determinants of health on a COVID-19 ICU: Frontline providers' perspectives on inequality in a time of pandemic

Efforts to improve health equity may be advanced by understanding health care providers' perceptions of the causes of health inequalities. Drawing on data from in-depth interviews with nurses and registered respiratory therapists (RRTs) who served on intensive care units (ICUs) during the first surge of the pandemic, this paper examines how frontline providers perceive and attribute the unequal impacts of COVID-19. It shows that nurses and RRTs quickly perceived the pandemic's disproportionate burden on Black and Latinx individuals and families. Providers attribute these inequalities to the social determinants of health, and also raise questions about how barriers to healthcare access may have made some patients more vulnerable to the worst consequences of COVID-19. Providers' perceptions of inequality and its consequences on COVID-19 ICUs were emotionally impactful and distressing, suggesting that this is a critical moment for offering clinicians practical strategies for understanding and addressing the persistent structural inequities that cause racial inequalities in health.

Moral distress in nursing students: Cultural adaptation and validation study

BACKGROUND

Moral distress, defined as moral suffering or a psychological imbalance, can affect nursing students. However, many new instruments or adaptations of other scales that are typically used to measure moral distress have not been used for nursing students.

AIM

This study aimed to translate, culturally adapt and evaluate the psychometric properties of an Italian version of the Moral Distress Scale for Nursing Students (It-ESMEE) for use with delayed nursing students (students who could not graduate on time or failed the exams necessary to progress to the next level).

RESEARCH DESIGN

The study used a cross-sectional research design.

PARTICIPANTS AND RESEARCH CONTEXT

Incidental sampling resulted in a sample of 282 delayed nursing students (mean age = 26.73 ± 4.43 years, 73% female) enrolled between May and August 2020 in a University of central Italy.

ETHICAL CONSIDERATIONS

The research protocol was approved by the internal review board of the university, and all participants provided their written informed consent.

RESULTS

The study confirmed a multidimensional second-order factorial structure for the It-ESMEE with five dimensions: improper institutional conditions to teach user care, authoritarian teaching practices, disrespect for the ethical dimension of vocational training, lack of competence of the teacher and commitment of ethical dimension of user care. The internal consistency was high (0.753-0.990 across the factors), and the standard error of measurement and smallest detectable change were adequate.

DISCUSSION

The It-ESMEE is able to assess moral distress in delayed nursing students with good validity and reliability. It can be used in research and to determine moral distress levels, helping teachers to monitor the condition in nursing students.

CONCLUSION

This instrument can help in comprehending moral distress, enabling students to develop coping and intervention strategies to maintain their well-being, and to ensure the quality of nurse education.

The Swedish translation and cultural adaptation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP)

BACKGROUND

Moral distress has been described as an emotionally draining condition caused by being prevented from providing care according to one's convictions. Studies have described the impact of moral distress on healthcare professionals, their situations and experiences. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) is a questionnaire that measures moral distress experienced by healthcare professionals at three levels: patient, system and team. The aim of this project was to translate and make a cultural adaption of the MMD -HP to the Swedish context.

METHODS

The questionnaire comprises 27 items, rated according to frequency and intensity on a five-point Likert scale (0-4). The procedure for translating MMD-HP followed WHO guidelines (2020). These entailed a forward translation from English to Swedish, a back translation, expert panel validation, pretesting and cognitive face-to-face interviews with 10 healthcare professionals from various professions and healthcare contexts.

RESULTS

The Swedish version of MMD-HP corresponds essentially to the concept of the original version. Parts of some items' had to be adjusted or removed in order to make the item relevant and comprehensible in a Swedish context. Overall, the cognitive interviewees recognized the content of the items which generally seemed relevant and comprehensible.

CONCLUSION

The Swedish version of MMD-HP could be a useful tool for measuring moral distress among healthcare professionals in a Swedish healthcare context.

Comparison of the Attitudes of Nurses and Physicians toward Palliative Care in Neonatal Intensive Care Units

Purpose

This study aimed to compare the attitudes of nurses and physicians toward neonatal palliative care and identify the barriers to and facilitators of neonatal palliative care, with the goal of improving palliative care for infants in neonatal intensive care units (NICUs).

Methods

This cross-sectional study analyzed data from the NICUs of seven general hospitals with 112 nurses and 52 physicians participating. Data were collected using the Neonatal Palliative Care Attitude Scale questionnaire.

Results

Only 12.5% of nurses and 11.5% of physicians reported that they had sufficient education in neonatal palliative care. In contrast, 89.3% of the nurses and 84.6% of the physicians reported that they needed further education. The common facilitators for both nurses and physicians were 1) agreement by all members of the department regarding the provision of palliative care and 2) informing parents about palliative care options. The common barriers for both nurses and physicians were 1) policies or guidelines supporting palliative care were not available, 2) counseling was not available, 3) technological imperatives, and 4) parental demands for continuing life support. Insufficient resources, staff, and time were also identified as barriers for nurses, whereas these were not identified as barriers for physicians.

Conclusion

It is necessary to develop hospital or national guidelines and educational programs on neonatal palliative care, and it is equally necessary to spread social awareness of the importance of neonatal palliative care.

Moral Distress in Clinicians Caring for Critically Ill Patients Who Require Mechanical Circulatory Support

BACKGROUND

Although use of mechanical circulatory support is increasing, it is unclear how providing such care affects clinicians' moral distress.

OBJECTIVE

To measure moral distress among intensive care unit clinicians who commonly care for patients receiving mechanical circulatory support.

METHODS

In this prospective study, the Moral Distress Scale-Revised was administered to physicians, nurses, and advanced practice providers from 2 intensive care units in an academic medical center. Linear regression was used to assess whether moral distress was associated with clinician type, burnout, or desire to leave one's job. Clinicians' likelihood of reporting frequent moral distress when caring for patients receiving mechanical circulatory support vs other critically ill patients also was assessed.

RESULTS

The sample comprised 102 clinicians who had a mean (SD) score of 100.5 (51.6) on the Moral Distress Scale- Revised. After adjustment for clinician characteristics, moral distress was significantly higher in registered nurses than physicians/advanced practice providers (115.9 vs 71.0, P < .001), clinicians reporting burnout vs those who did not (114.7 vs 83.1, P = .003), and those considering leaving vs those who were not (121.1 vs 89.2, P = .001). Clinicians were more likely to report experiencing frequent moral distress when caring for patients receiving mechanical circulatory support (26.5%) than when caring for patients needing routine care (10.8%; P = .004), but less likely than when caring for patients with either chronic critical illness (57.8%) or multisystem organ failure (56.9%; both P < .001).

CONCLUSION

Moral distress was high among clinicians who commonly care for patients receiving mechanical circulatory support, suggesting that use of this therapy may affect well-being among intensive care unit clinicians.

Exploring the experiences of nurses' moral distress in long-term care of older adults: a phenomenological study

Background

Moral distress is a poorly defined and frequently misunderstood phenomenon, and little is known about its triggering factors during ICU end-of-life decisions for nurses in Iran. This study aimed to explore the experiences of nurses’ moral distress in the long-term care of older adults via a phenomenological study.

Methods

A qualitative, phenomenological study was conducted with 9 participants using in-depth semi-structured interviews. The purpose was to gain insight into the lived experiences and perceptions of moral distress among ICU nurses in hospitals affiliated with Tehran University of Medical Sciences during their long-term care of older adults.

Results

Five major themes are identified from the interviews: advocating, defense mechanisms, burden of care, relationships, and organizational issues. In addition, several subthemes emerged including respectful end of life care, symptom management, coping, spirituality, futile care, emotional work, powerlessness, relationships between patients and families, relationships with healthcare teams, relationships with institutions, inadequate staffing, inadequate training, preparedness, education/mentoring, workload, and support.

Conclusions

This qualitative study contributes to the limited knowledge and understanding of the challenges nurses face in the ICU. It also offers possible implications for implementing supportive interventions.

Burnout and intent-to-leave in physical therapists: a preliminary analysis of factors under organizational control

METHODS

Twelve hundred PTs were sent a survey packet including the 20-item Ethics Environment Questionnaire (EEQ) and additional items inquiring about contemporary practice factors. Returned packets (n = 340) were analyzed utilizing correlational and regression analyses to determine relationships between ethical environment, burnout, intent-to-leave, productivity standards, billing and coding requirements and ability to provide pro-bono services.

RESULTS

There was a strong correlation between PTs' view of organizational ethics and burnout (T_{b =} -0.55), and a moderate correlation between organizational ethics and intent-to-leave (T_b = -0.43). There was also a strong relationship between burnout/intent-to-leave and practice factors such as productivity standards, billing/coding policy, and organizational provision of pro-bono services (p ≤ 0.01). Finally, there was a moderate correlation between PTs' view of organizational ethics and practice factors such as productivity standards (T_b = 0.46) and billing and coding policy (T_b = -0.45).

CONCLUSIONS

Contemporary practice factors such as productivity standards and billing/coding practices are related PT's perception of ethical workplace environment and both are related to PT burnout and intent-to-leave. Factors identified in this study related to burnout are all under organizational control.

A Longitudinal Study of the Impact of Schwartz Center Rounds on Moral Distress

Moral distress occurs when moral integrity is compromised and can affect any healthcare professional. This study examined the impact of Schwartz Center Rounds (SCRs) on moral distress using a longitudinal, quasi-experimental design to examine SCR attendees from 2015 to 2019. Data were collected via a 2-part survey composed of demographics and Moral Distress Thermometer (MDT) readings before rounds and immediately after rounds. Most participants experienced either no change in moral distress (50.6%) or a decrease in moral distress (33.7%) after attending one of the SCRs. Participants who worked with adult populations had higher moral distress after participation for most topics. An increase in moral distress was associated with a longer time in the current position. Fifty percent of the physicians had a decrease in their moral distress immediately after the rounds. Schwartz Center Rounds is a promising approach to foster high-functioning teams while promoting wellness and mitigating moral distress among employees.

Moral Distress Among Interdisciplinary Critical Care Team Members at a Comprehensive Cancer Center

BACKGROUND

Moral distress (MD) has been linked to health care professional burnout, intent to leave, and decreased quality of care.

OBJECTIVES

The aim of this study was to describe the perceptions of MD among critical care interdisciplinary team members and assess the association of MD with team member characteristics.

METHODS

A descriptive cross-sectional design was used with interdisciplinary team members in an intensive care unit setting at an NCI-designated Comprehensive Cancer Center in the southeastern United States. The Measure of Moral Distress for Healthcare Professionals was provided to registered nurses, oncology technicians, providers, respiratory therapists, and ancillary team members (social workers, pharmacists, dietitians).

RESULTS

A total of 67 team members completed the survey. Mean responses for 3 items were higher than 8 (halfway point of scale): "Follow family's insistence to continue aggressive treatment even though I believe it is not in the best interest of patient" (mean [SD], 11.4 [4.8]); "Continue to provide aggressive treatment for a patient most likely to die regardless of this treatment when no one will make a decision to withdraw it" (mean [SD], 10.5 [5.3]); and "Witness providers giving 'false hope' to patient/family" (mean [SD], 9.0 [5.3]). Higher responses on the "Continuing to provide aggressive treatment" item was associated with having "considered leaving due to MD" (P = .027) and "considering leaving now due to MD" (P = .016). Higher total scores were related to having left or considered leaving a job (P = .04). When examining education level, registered nurses with a master's degree (n = 5) exhibited the most MD (P = .04).

CONCLUSION

This study suggests that the Measure of Moral Distress for Healthcare Professionals is useful in identifying areas for focused efforts at reducing MD for interdisciplinary teams.

Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment

Background

To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient.

Methods

Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care.

Results

A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves.

Conclusion

The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03712-4.

Moral Distress and Other Wellness Measures in Canadian Critical Care Physicians

Rationale: Understanding the magnitude of moral distress and its associations may point to solutions. Objectives: To understand the magnitude of moral distress and other measures of wellness in Canadian critical care physicians, to determine any associations among these measures, and to identify potentially modifiable factors. Methods: This was an online survey of Canadian critical care physicians whose e-mail addresses were registered with either the Canadian Critical Care Society or the Canadian Critical Care Trials Group. We used validated measures of moral distress, burnout, compassion fatigue, compassion satisfaction, and resilience. We also measured selected individual, practice, and workload characteristics. Results: Of the 499 physicians surveyed, 239 (48%) responded and there were 225 usable surveys. Respondents reported moderate scores of moral distress (107 ± 59; mean ± standard deviation, maximum 432), one-third of respondents had considered leaving or had previously left a position because of moral distress, about one-third met criteria for burnout syndrome, and a similar proportion reported medium-high scores of compassion fatigue. In contrast, about one-half of respondents reported a high score of compassion satisfaction, and overall, respondents reported a moderate score of resilience. Each of the "negative" wellness measures (moral distress, burnout, and compassion fatigue) were associated directly with each of the other "negative" wellness measures, and inversely with each of the "positive" wellness measures (compassion satisfaction and resilience), but moral distress was not associated with resilience. Moral distress was lower in respondents who were married or partnered compared with those who were not, and the prevalence of burnout was lower in respondents who had been in practice for longer. There were no differences in any of the wellness measures between adult and pediatric critical care physicians. Conclusions: Canadian critical care physicians report moderate scores of moral distress, burnout, and compassionate fatigue, and moderate-high scores of compassion satisfaction and resilience. We found no modifiable factors associated with any wellness measures. Further quantitative and qualitative studies are needed to identify interventions to reduce moral distress, burnout, and compassion fatigue.

Moral distress among healthcare professionals working in intensive care units in Spain

OBJECTIVE

To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs).

DESIGN

Cross-sectional, prospective study.

SETTING

ICUs in Spain.

PARTICIPANTS

HCPs currently working in Spanish ICUs.

INTERVENTIONS

A 55-item questionnaire was electronically distributed.

MAIN VARIABLES

The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS).

RESULTS

In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD.

CONCLUSIONS

In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Leadership, professional quality of life and moral distress during COVID-19: A mixed-methods approach

AIM

To understand the impact of professional stressors on nurses' and other health care providers' professional quality of life and moral distress as they cared for patients during the COVID-19 pandemic.

BACKGROUND

Health care providers caring for patients during the COVID-19 pandemic are at increased risk of decreased professional quality of life and increased moral distress.

METHODS

A convergent mixed-methods design and snowball sampling was used to collect survey data (n = 171) and semi-structured interviews (n = 23) among health care providers working in the inpatient setting.

RESULTS

Perceived lack of support from executive leadership, access to personal protective equipment and constantly changing guidelines led to decreased professional quality of life and increased moral distress among health care providers.

CONCLUSION

Findings from this study indicate that shared governance, disaster management training and enhanced communication may assist executive leadership to reduce the likelihood of decreased professional quality of life and increased moral distress in front line health care providers.

IMPLICATIONS FOR NURSING MANAGEMENT

Following the principles of shared governance may assist executive leadership to promote and acknowledge the significance of the role of health care providers at the bedside. Additionally, disaster management training and open communication are crucial to ensure that health care providers are adequately informed and supported at the bedside.

Recommendations for navigating the experiences of moral distress: A scoping review

BACKGROUND

Moral distress is a complex ethical phenomenon that occurs when one is not able to act according to their moral judgement. Consequences of moral distress negatively impact nurses, patient care, and the healthcare system. There is limited evidence on specific approaches to prepare nurses to manage these ethical situations.

AIM

The aim of this scoping review is to identify moral distress interventions for nurses who provide direct patient care, identify gaps in the current moral distress research, and determine areas of focus for future research on this topic.

METHODS

We employed the framework outlined by Levac, Colquhoun, and O'Brien and Arksey and O'Malley to conduct a scoping review. These steps included the: identification of the research question, identification of relevant studies, study selection, charting the data, collating, summarizing, and reporting the results. We appraised the quality of included studies using the Mixed Methods Appraisal Tool.

RESULTS

We identified 5206 articles from the selected databases. Once duplicates were removed, two independent reviewers each screened 4043 title and abstracts. We included 554 articles for full-text screening, with 10 studies included based on inclusion and exclusion criteria. Study designs included before-after studies (n = 4), randomized control trials (n = 3), concurrent mixed-methods studies (n = 2), and one controlled before-after study. All studies were conducted in acute care settings. In four studies, interventions focused on informing nurses on moral distress. Two interventions focused on increasing the nurses' reflexivity on their workplace experiences. One intervention included formal clinical mentoring and clinical ethics support through interprofessional rounds. Two studies utilized a multicomponent intervention. The overall moral distress scores significantly decreased after intervention implementation in three included studies. Three additional studies showed significant differences in specific survey item scores (e.g., "provision of less-than-optimal care" and "caring for patients they did not feel qualified to care for"), as compared to overall scores, after intervention implementation. In 70% of studies the amount of quality criteria met were 60% or higher according to the Mixed Methods Appraisal Tool.

CONCLUSION

Our review is the first to synthesize intervention studies pertaining to moral distress among nurses. The findings of this review demonstrate that there is no clear pattern regarding which strategies consistently minimize the effects of moral distress among nurses. Future interventions should be tested more broadly by increasing the sample size, assessing length of intervention in relation to moral distress scores, expanding the interventions to other units and institutions, and including other healthcare professionals. Tweetable abstract: We reviewed interventions to help nurses with moral distress. Findings show no clear pattern of strategies to minimize their moral distress.

Exploiting Technology to Popularize Goals-of-Care Conversations and Advance Care Planning

BACKGROUND

Goals-of-care conversations are a central component of high-quality patient-centered care. However, clinicians may not engage in such conversations until patients are critically ill.

OBJECTIVE

To assess the frequency and quality of goals-of-care conversation documentation among patients who died in an intensive care unit, and then to develop and implement mechanisms to improve the quantity and quality of such conversations.

METHODS

A baseline retrospective medical records review of intensive care unit deaths that occurred within 1 year was conducted to assess the barriers to high-quality goals-of-care conversations. A nurse-led inter-professional task force was formed to address possible solutions.

INTERVENTIONS

A new electronic health record tab, note type, and preformatted template known as a SmartPhrase for goals-of-care conversations were created. Nurses and physicians were educated and encouraged to perform and document goals-of-care conversations.

RESULTS

Before implementation of the initiative, the electronic health record lacked a consistent place to document goals-of-care conversations, and such conversations were not occurring until patients required intensive care. Moreover, the content of documentation of the conversations was inconsistent. Three years after implementation of the initiative, the goals-of-care conversation documentation tab was used for 75% of hospital deaths, and 67% of goals-of-care conversation notes included use of the SmartPhrase template.

CONCLUSIONS

Electronic health record platforms can be used to improve the frequency, consistency of documentation, and quality of goals-of-care conversations. A standardized process coupled with effective work tools can foster a culture of advance care planning.

A Tool Adaptation Workshop for Moral Distress in Military Critical Care Nurses

PURPOSE

The US military healthcare services provide the highest level of trusted medical care to its members and to the world population during catastrophic events. These services can be difficult, making moral and ethical situations commonplace. Moral distress results when actions are inconsistent with personal or professional beliefs, resulting in a loss of moral integrity. Moral distress research is well established in the civilian literature and results in poor outcomes and increased expenses. There is little research studying moral distress in military providers.

DESCRIPTION OF THE PROJECT

A clinical nurse specialist-led workshop was conducted with military and civilian experts. The expert panel reviewed the literature, examined instruments, and reviewed tool items for applicability to military healthcare providers.

OUTCOME

The team determined the existing civilian moral distress tool was applicable to military providers. Twelve additional items were added to the modified tool. A tool testing plan was developed to test the tool in military critical care nurses on the last day of the workshop for the next phase of this project.

CONCLUSION

The civilian moral distress tool was adapted for a military version and will be tested in the next phase of the project.

Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study

BACKGROUND

Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems.

OBJECTIVE

We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees.

DESIGN

Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress.

PARTICIPANTS

Sixteen internal medicine residents in the US and fourteen junior doctors in the UK.

APPROACH

The work was analyzed using thematic analysis.

KEY RESULTS

Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it.

CONCLUSION

This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries' healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.

An effective in-hospital chaplaincy-led care program for nurses: Tea for the soul a qualitative investigation

Tea for the Soul (TFS) is an understudied care model, addressing bereavement and other emotional needs of nurses related to impactful patient care experiences. Nurses are at high risk for compassion fatigue, moral distress, and burnout. Facilitated by a Chaplain, the TFS program provides participants a venue to express their feelings and explore ways of adapting effectively with the death of a patient, and other traumatic workplace experiences. In this qualitative grounded theory study, hospital nurses (N = 7) who participated in TFS were interviewed. IRB approval was obtained. Questions were constructed within the context of the medical center research council and asked if TFS: (a) was personally beneficial, (b) helped nurses feel better about their work, and (c) affected job satisfaction. Four core themes emerged: (a) Nurses' Self-Care, (b) Professional Practice, (c) Community, and (d) Improved Patient Care Outcomes. The Roy Adaptation Model, Group Identity Mode was applied to the content analysis. Overarching themes were Compassionate Service, Ministry of Presence, Reflective Practice, and Sacred Encounters. Nurses reported that TFS facilitated a spiritual respite and a sense of enhanced community and was a source of strength and coping, thus may aid in the promotion of nurse well-being and the amelioration of moral distress, compassion fatigue, and burnout.

Beyond technology, drips, and machines: Moral distress in PICU nurses caring for end-of-life patients

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long-term consequences to the individual. Critical care areas are fraught with ethical issues, and end-of-life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality.

[The Tübingen Model "Ethics Consultants on the Ward": a pilot project to establish decentralized structures of clinical ethics consultation at a university hospital]

DEFINITION OF THE PROBLEM

Clinical ethics committees form an integral part of ethics management and organizational ethics in clinical healthcare facilities. However, working mostly reactive and not being anchored in the corresponding organizational levels, such instruments are limited in terms of effectiveness.

ARGUMENTS

Based on these shortcomings of clinical ethics consultation the multiprofessional working group "Ethics" at the University Hospital Tübingen, Germany has endeavored to design and implement new structures for sustainable ethical decision-making processes on its hospital wards. The Tübingen Model "Ethics Consultants on the Ward" is a pilot project intended to appoint specifically trained nursing staff on all wards as contact partners for ethical issues. Thus, the Tübingen Model represents an extension to established structures of clinical ethics consultation and complements existing top-down strategies.

CONCLUSIONS

This article presents the objectives of the Tübingen Model and describes initial experiences in its implementation. After explaining their role within the existing structures of ethics consultation at the hospital, the tasks of the ethics consultants within and across the hospital's wards are presented. Furthermore, the qualification program for ethics consultants (basic and advanced training) as well as a train-the-trainer concept are presented, which support an in-depth development of competencies in nursing as well as medical ethics and provide confidence in the reflection and decision-making processes on the ward.

An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy

BACKGROUND

Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress.

OBJECTIVES

The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points.

METHODS

Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used.

RESULTS

At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly.

DISCUSSION

This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

Critical Care Nurses' Qualitative Reports of Experiences With Physician Behaviors, Nursing Issues, and Other Obstacles in End-of-Life Care

BACKGROUND

Critical care nurses (CCNs) frequently provide end of life (EOL) care in intensive care units (ICUs). Obstacles to EOL care in ICUs exist and have been previously published along with reports from CCNs. Further data exploring obstacles faced during ICU EOL care may increase awareness of common EOL obstacles. Research focusing on obstacles related to physician behaviors and nursing issues (and others) may provide improvement of care.

OBJECTIVE

The aim of this study was to gather first-hand data from CCNs regarding obstacles related to EOL care.

METHODS

A random, geographically dispersed sample of 2000 members of the American Association of Critical-Care Nurses was surveyed. Responses from an item asking CCNs to tell us of the obstacles they experience providing EOL care to dying patients were analyzed.

RESULTS

There were 104 participants who provided 146 responses to this item reflecting EOL obstacles. These obstacles were divided into 11 themes; 6 physician-related obstacles and 5 nursing- and other related obstacles. Major EOL ICU barrier themes were inadequate physician communication, physicians giving false hope, poor nurse staffing, and inadequate EOL care education for nurses.

DISCUSSION AND CONCLUSION

Poor physician communication was the main obstacle noted by CCNs during ICU EOL care, followed by physicians giving false hope. Heavy patient workloads with inadequate staffing were also a major barrier in CCNs providing EOL care.

Intensive care unit nurses living through COVID-19: A qualitative study

Aims

To understand how nurses experience providing care for patients hospitalized with COVID‐19 in intensive care units.

Background

As hospitals adjust staffing patterns to meet the demands of the pandemic, nurses have direct physical contact with ill patients, placing themselves and their families at physical and emotional risk.

Methods

From June to August 2020, semi‐structured interviews were conducted. Sixteen nurses caring for COVID‐19 patients during the first surge of the pandemic were selected via purposive sampling. Participants worked in ICUs of a quaternary 1,000‐bed hospital in the Northeast United States. Interviews were transcribed verbatim, identifiers were removed, and data were coded thematically.

Results

Our exploratory study identified four themes that describe the experiences of nurses providing care to patients in COVID‐19 ICUs during the first surge: (a) challenges of working with new co‐workers and teams, (b) challenges of maintaining existing working relationships, (c) role of nursing leadership in providing information and maintaining morale and (d) the importance of institutional‐level acknowledgement of their work.

Conclusions

As the pandemic continues, hospitals should implement nursing staffing models that maintain and strengthen existing relationships to minimize exhaustion and burnout.

Implications for Nursing Management

To better support nurses, hospital leaders need to account for their experiences caring for COVID‐19 patients when making staffing decisions.

Moral distress in nurses caring for patients with Covid-19

BACKGROUND

Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic.

OBJECTIVE

To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency.

RESEARCH DESIGN

A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in the acute care units within large academic medical systems in Maryland and New York City during April to June 2020.

ETHICAL CONSIDERATIONS

We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore.

RESULTS

We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies.

DISCUSSION/CONCLUSION

Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses' moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences.

Healthcare professionals' values about and experience with facilitating end-of-life care in the adult intensive care unit

OBJECTIVES

To evaluate values and experience with facilitating end-of-life care among intensive care professionals (registered nurses, medical practitioners and social workers) to determine perceived education and support needs.

RESEARCH DESIGN

Using a cross-sectional study design, 96 professionals completed a survey on knowledge, preparedness, patient and family preferences, organisational culture, resources, palliative values, emotional support, and care planning in providing end-of-life care.

SETTING

General adult intensive care unit at a tertiary referral hospital.

RESULTS

Compared to registered nurses, medical practitioners reported lower emotional and instrumental support after a death, including colleagues asking if OK (p = 0.02), lower availability of counselling services (p = 0.01), perceived insufficient time to spend with families (p = 0.01), less in-service education for end-of-life topics (p = 0.002) and symptom management (p = 0.02). Registered nurses reported lower scores related to knowing what to say to the family in end-of-life care scenarios (p = 0.01).

CONCLUSION

Findings inform strategies for practice development to prepare and support healthcare professionals to provide end-of-life care in the intensive care setting. Professionals reporting similar palliative care values and inclusion of patient and family preferences in care planning is an important foundation for planning interprofessional education and support with opportunities for professionals to share experiences and strengths.

Translation and validation of the Japanese version of the measure of moral distress for healthcare professionals

OBJECTIVES

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP).

METHODS

We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted.

RESULTS

308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument.

CONCLUSIONS

The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.

End-of-Life Care: Improving Communication and Reducing Stress

This quality improvement initiative originated in the cardiac intensive care unit (CICU) at a 637-bed licensed Magnet teaching hospital with the rating of level 1 trauma center. The CICU has 12 beds, with a staff of 59 nurses (RNs). The nursing staff expressed increased stress and discomfort when communicating with patients and their families when providing end-of-life care. Selected evidence-based techniques for stress reduction and active listening skills were taught in 4- to 5-minute mini sessions during the morning huddle 3 days per week for 4 weeks. The program was evaluated using pretest, posttest, and 2 follow-up surveys composed of 5 statements and 2 open-ended questions. The survey tool was developed by researchers in accordance with the relevant literature. The results showed improved communication as demonstrated by the surveys. Nurses also reported feeling more supported by their colleagues and supervisors. The project was conducted in 1 CICU, therefore limiting the generalizability of the results.

How Can I Survive This?: Coping During Coronavirus Disease 2019 Pandemic

Worldwide, health-care professionals are experiencing unprecedented stress related to the coronavirus disease 2019 pandemic. Responding to a new virus for which there is no effective treatment yet and no vaccine is beyond challenging. Moral distress, which is experienced when clinicians are unable to act in the way that they believe they should, is often experienced when they are dealing with end-of-life care issues and insufficient resources. Both factors have been widespread during this pandemic, particularly when patients are dying alone and there is a lack of personal protection equipment that plagues many overburdened health-care systems. We explore here, guided by evidence, the concept and features of moral distress and individual resilience. Mitigation strategies involve individual and institutional responsibilities; the importance of solidarity, peer support, psychological first aid, and gratitude are highlighted.

Evaluation of NICU Healthcare Providers' Experience of Patient Ethics and Communication Excellence (PEACE) Rounds

BACKGROUND

Neonatal intensive care (NICU) providers may experience distress due to controversial orders or the close relationships they form with neonates' families. A "Patient Ethics and Communications Excellence [PEACE] Rounds" intervention developed at Indiana University proved to significantly relieve distress by facilitating interdisciplinary discussions of clinically and ethically challenging issues associated with pediatric intensive care (PICU) patient care. NICU healthcare providers face similar challenges and will benefit from understanding the potential efficacy of PEACE Rounds in this setting.

PURPOSE

This study describes the experiences of NICU healthcare providers who participate in PEACE Rounds and evaluates their perceptions of how it affects their distress levels, contributes to interdisciplinary collaboration, and influences their understanding of ethical decision-making.

METHODS

Researchers conducted semi-structured interviews with 24 intervention participants, observed 12 interventions, facilitated a validation focus group, and performed a constructionist thematic analysis and triangulation based on data from transcribed recordings.

FINDINGS

PEACE Rounds improved interdisciplinary communication and collaboration and demonstrated restorative value through the benefits of voice and collective support. The intervention may reduce, but not replace, the need for formal ethics consultations.

IMPLICATIONS FOR PRACTICE

PEACE Rounds may potentially improve interdisciplinary communications and collaboration, relieve employee distress, and reduce ethics consultations.

IMPLICATIONS FOR RESEARCH

Studies of PEACE Rounds undertaken in other clinical settings, and facilitated by a nurse educator, will help assess the potential benefits of greater reach and access and the efficacy of less structured ethics discussions.

Moral distress and its contributing factors among emergency department nurses: A cross-sectional study in Iran

BACKGROUND

Moral Distress (MD) is a common experience in nursing practice and constitutes one of the main reasons for professional burnout, job withdrawal, fatigue, and avoidance of patient care among nurses. The causes, frequency and severity of MD vary according to the ward and hospital of service. The present study was conducted to determine the frequency and severity of MD and its contributing factors among Emergency Department (ED) nurses in Iran.

METHODS

This descriptive cross-sectional study was conducted in 2019.A total of 203 participants were selected by census sampling from the 248 nurses working in the EDs of hospitals in Semnan Province, Iran. Data were collected using Corley's Moral Distress Scale-Revised and analyzed using descriptive and inferential statistics.

FINDINGS

The mean severity and frequency of MD were 1.36 ± 0.74 and 1.20 ± 0.68 out of 4, respectively. The MD levels were significantly higher in female nurses (p = 0.002), those under 30 years of age (p = 0.003), with less than ten years' work experience (p = 0.03), and with higher levels of education (p < 0.001). In addition, inverse and significant relationships were found between MD and the nurses' age (r = -0.202,p = 0.004) and work experience(r = -0.149, p = 0.034).

CONCLUSION

According to the results, nurses had moderate levels of MD. Numerous factors, including age, gender, work experience, and education, were associated with the total MD score.To reduce MD and its negative effects on nurses, it is necessary to address these factors and appropriately plan to identify and manage MD so as to improve the quality of nursing care.

Ethical climate and moral distress in paediatric oncology nursing

BACKGROUND

Ethical climate and moral distress have been shown to affect nurses' ethical behaviour. Despite the many ethical issues in paediatric oncology nursing, research is still lacking in the field.

RESEARCH AIM

To investigate paediatric oncology nurses' perceptions of ethical climate and moral distress.

RESEARCH DESIGN

In this cross-sectional study, data were collected using Finnish translations of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Data analysis includes descriptive statistics and non-parametric analyses.

RESPONDENTS AND RESEARCH CONTEXT

Ninety-three nurses, working at paediatric oncology centres in Finland, completed the survey.

ETHICAL CONSIDERATIONS

According to Finnish legislation, no ethical review was needed for this type of questionnaire study. Formal research approvals were obtained from all five hospitals. Return of the questionnaire was interpreted as consent to participate.

RESULTS

Ethical climate was perceived as positive. Although morally distressing situations were assessed as highly disturbing, in general they occurred quite rarely. The situations that did appear often reflected performing procedures on school-aged children who resist such treatment, inadequate staffing and lack of time. Perceptions of ethical climate and frequencies of morally distressing situations were inversely correlated.

DISCUSSION

Although the results echo the recurrent testimonies of busy work shifts, nurses could most often practise nursing the way they perceived as right. One possible explanation could be the competent and supportive co-workers, as peer support has been described as helpful in mitigating moral distress.

CONCLUSION

Nurturing good collegial relationships and developing manageable workloads could reduce moral distress among nurses.